Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
J Vasc Surg. 2019 Jan;69(1):148-155. doi: 10.1016/j.jvs.2018.04.049. Epub 2018 Jun 28.
The peroneal artery is a well-established target for bypass in patients with critical limb ischemia (CLI). The objective of this study was to evaluate the outcomes of peroneal artery revascularization in terms of wound healing and limb salvage in patients with CLI.
Patients presenting between 2006 and 2013 with CLI (Rutherford 4-6) and isolated peroneal runoff were included in the study. They were divided into patients who underwent bypass to the peroneal artery and those who underwent endovascular peroneal artery intervention. Demographics, comorbidities, and follow-up data were recorded. Wounds were classified by Wound, Ischemia, foot Infection (WIfI) score. The primary outcome was wound healing; secondary outcomes included mortality, major amputation, and patency.
There were 200 limbs with peroneal bypass and 138 limbs with endovascular peroneal intervention included, with mean follow-up of 24.0 ± 26.3 and 14.5 ± 19.1 months, respectively (P = .0001). The two groups were comparable in comorbidities, with the exception of the endovascular group's having more patients with cardiac and renal disease and diabetes mellitus but fewer patients with smoking history. Based on WIfI criteria, ischemia scores were worse in bypass patients, but wound and foot infection scores were worse in endovascular patients. Perioperatively, bypass patients had higher rates of myocardial infarction (4.5% vs 0%; P = .012) and incisional complications (13.0% vs 4.4%; P = .008). At 12 months, the bypass group compared with the endovascular group had better primary patency (47.9% vs 23.4%; P = .002) and primary assisted patency (63.6% vs 42.2%; P = .003) and a trend toward better secondary patency (74.2% vs 63.5%; P = .11). There were no differences in the rate of wound healing (52.6% vs 37.7% at 1 year; P = .09) or freedom from major amputation (81.5% vs 74.7% at 1 year; P = .37). In a multivariate analysis, neuropathy was associated with improved wound healing, whereas WIfI wound score, cancer, chronic renal insufficiency, and smoking were associated with decreased wound healing. Treatment modality was not a significant predictor (P = .15).
Endovascular peroneal artery intervention results in poorer primary and primary assisted patency rates than surgical bypass to the peroneal artery but provides similar wound healing and limb salvage rates with a lower rate of complications. In appropriately selected patients, endovascular intervention to treat the peroneal artery is a low-risk intervention that may be sufficient to heal ischemic foot wounds.
在患有严重肢体缺血（CLI）的患者中，腓动脉是旁路移植的既定靶标。本研究的目的是评估腓动脉血运重建在 CLI 患者的伤口愈合和肢体挽救方面的结果。
研究纳入了 2006 年至 2013 年间患有 CLI（Rutherford 4-6）和孤立性腓动脉流出的患者。他们被分为接受腓动脉旁路移植的患者和接受经皮腔内腓动脉干预的患者。记录患者的人口统计学、合并症和随访数据。伤口根据伤口、缺血、足部感染（WIfI）评分进行分类。主要结局是伤口愈合；次要结局包括死亡率、主要截肢和通畅率。
共有 200 条接受腓动脉旁路移植的肢体和 138 条接受经皮腔内腓动脉干预的肢体纳入研究，平均随访时间分别为 24.0±26.3 个月和 14.5±19.1 个月（P=0.0001）。两组的合并症相似，但经皮腔内组的心脏病、肾病和糖尿病患者更多，而吸烟史患者更少。根据 WIfI 标准，旁路组的缺血评分更差，但经皮腔内组的伤口和足部感染评分更差。围手术期，旁路组的心肌梗死发生率（4.5% vs 0%；P=0.012）和切口并发症发生率（13.0% vs 4.4%；P=0.008）更高。在 12 个月时，与经皮腔内组相比，旁路组的初始通畅率（47.9% vs 23.4%；P=0.002）和初始辅助通畅率（63.6% vs 42.2%；P=0.003）更好，并且二级通畅率也有更好的趋势（74.2% vs 63.5%；P=0.11）。两组在伤口愈合率（1 年时 52.6% vs 37.7%；P=0.09）或免于主要截肢率（1 年时 81.5% vs 74.7%；P=0.37）方面无差异。多变量分析显示，神经病变与伤口愈合改善相关，而 WIfI 伤口评分、癌症、慢性肾功能不全和吸烟与伤口愈合不良相关。治疗方式不是显著的预测因素（P=0.15）。
与腓动脉旁路移植相比，经皮腔内腓动脉干预导致初始和初始辅助通畅率较低，但在并发症发生率较低的情况下，可提供相似的伤口愈合和肢体挽救率。在适当选择的患者中，治疗腓动脉的腔内介入是一种低风险的介入方法，可能足以治愈缺血性足部伤口。
